- Overview Part 1 -
Christolyn Raj
Adjustable suture strabisumus surgery

 Adjustable sutures
 Indications
 Patient selection
 Anaesthetic considerations
 Techniques
 Complications
Adjustable suture strabisumus surgery

• Principle : to secure EOM to sclera with a sliding knot , then when pt is awake , the length of suture b/w attachment site and muscle may be shortened or lengthened
 First described by Claude Worth , first practised by Jampolsky 1975
 No prospective RCTs to date on selective advantage of adjustable sutures
 Few reports on use of adjustable sutures on children
 Adjustable sutures in strabismus surgery . Hunter, D. Dingeman RS et al. J
Paed Opthal 2009.
 Number of surgeons decribe adjustable sutures in adults to improve immediate post-op alignment [refs 3, 17, 22, 26, 30-32]
 Summary by Hunter, Dinegeman et al., promote use of adjustable sutures on ALL adults , including those with comitant strabismus & no prior surgery
 Authors also describe use in children who met select criteria
Adjustable suture strabisumus surgery

• Restrictive strabismus eg: TED
• Previous trauma or surgery
• Slipped, lost, disinserted muscles
• Incomitant deviations eg : Duane’s syndrome ,
MG
• Any longstanding, complex strabismus
Adjustable suture strabisumus surgery

 Adjustable sutures can be used with recessed or resected muscles and also been successfully described on superior oblique tendon .
Goldenberg-Cohen N, et al. 2005. Strabismus 13;5-10.
• Most surgeons advocate adjustable suture technique in children aged 12 yrs & older
• and only younger if co-operative & may require two stages of anesthesia
• Active participation of parents is a key factor (Dawson et al. 2001)
Can perfom “Q-tip” test to identify suitable pts – consists of touching a cotton tip to the MR or LR aspect of the unanesthetized bulbar conjunctiva as a pre- test tolerability
 If patient fails Q-tip test : consider non-adjustable suture surgery or arrange for back-up sedation
Adjustable suture strabisumus surgery

1). Recovery of extraocular muscle function
-GA: EOM function recovers when pt awakes
-LA: short acting agents require 5hrs minimum for motility to recover
2). Patient comfort & alertness in recovery
-pre-medication: for post-op nausea
-induction with propofol preferable , shorter acting muscle relaxants preferable
-avoid opiate analgesia which may cause sedation & nausea
-topical tetracaine is often sufficient
-ketorolac early intraop is another option /7 is m.effective
Adjustable suture strabisumus surgery

3). Post-op nausea & vomiting
-ondansetron is very effective & has few SE’s
-use with dexamethasone may augment effects of ondansetron
4). Sedation protocol for suture adjustment
-mainly for unco-operative pts
-inform anaethetist
-should be monitored in recovery room setting to ensure airway & basic monitoring equipment is readily available
-may need propofol induction dose
Adjustable suture strabisumus surgery

Limbal vs fornix approach o Limbal appoach provides broad exposure but requires conjunctival closure post suture adjustment o Fornix approach may be more comfortable as sutures are covered
Technique
Bow tie o Sutures ae tied together in a single-loop bow-tie like a shoelace o At adjustment the bow is untied , muscle adjusted & re-tied, bow cut & converted to a square knot
Sliding-noose o sutures are passed through scleral tunnels emerging <1mm apart , a noose is created by tying a separate piece of suture around the scleral sutures
Adjustable suture strabisumus surgery

Adjustable suture strabisumus surgery

Semi-adjustable sutures o Described by (Kushner et al.) to reduce muscle slippage whilst preserving potential for adjustment o Involves suturing corners of muscle to sclera & placing centre of muscle on adjustable
Authors’ preferred technique o Describes “noose” suture o For adjustable recession standard hangback doses used o For adjustable resection an extra 1-3mm muscle is resected , then muscle allowed to hang back by same amt o After the sutures are passed , they are pulled to original insertion then these sutures are secured to each other with an overhand knot- these joined sutures are ‘ple sutures’ o For the adjustable noose , an absorbable suture is used , placed underneath the pole sutures & wrapped around a second time, finally tying a square knot to prevent slippage o At adjustment the bow is untied , muscle adjusted & re-tied, bow cut & converted to a square knot
Adjustable suture strabisumus surgery

Adjustable suture strabisumus surgery

Adjustable suture strabisumus surgery

*Intra-adjustment complications :
 Nausea& vomiting
 oculucardiac reflex
 possible bradycardia
 Syncope
*Postoperative healing process may be very inflammatory :
 conjunctival suture granulomas etc
 Adhesions
Adjustable suture strabisumus surgery

• Adjustable sutures provide a second chance to improve outcomes of initial strabismus surgery
• However….
 They can add to complexity of case
 Require appropriate patient selection
 Evidence to validate their advantage over convential surgery is still not universally acknowledged
 Difficult learning curve involved
Adjustable suture strabisumus surgery